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Introduction
The hepatorenal syndrome (HRS) is defined as the development of renal failure in patients with severe liver disease (acute or chronic) in the absence of any other identifiable cause of renal pathology. It is diagnosed following exclusion of other causes of renal failure in patients with liver disease such as hypovolaemia, drug nephrotoxicity, sepsis, or glomerulonephritis. A similar syndrome may also occur in the setting of acute liver failure.
DIAGNOSTIC CRITERIA
The International Ascites Club (1996) group defined the diagnostic criteria for hepatorenal syndrome1 and these are listed in table 1.
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Major criteria for a diagnosis of hepatorenal syndrome
Two patterns of HRS are observed in clinical practice and these were defined by the International Ascites club.1
Type 1 hepatorenal syndrome is an acute form of HRS in which renal failure occurs spontaneously in patients with severe liver disease and is rapidly progressive. It is characterised by marked reduction of renal function, as defined by doubling of the initial serum creatinine to a level greater than 225 μM, or a 50% reduction in initial 24 hour creatinine clearance to <20 ml/min within two weeks. The development of type 1 HRS has a poor prognosis with 80% mortality at two weeks.2 Renal function may recover spontaneously following improvement in liver function.2 This is most frequently observed in acute liver failure or alcoholic hepatitis, or following acute decompensation on a background of cirrhosis. These patients are usually jaundiced with a significant coagulopathy. Death often results from a combination of hepatic and renal failure or variceal bleeding.
Type 2 hepatorenal syndrome usually occurs in patients with diuretic resistant ascites. Renal failure has a slow course, in which it may deteriorate over months. It is associated with a poor prognosis3 although the survival time is longer than that of …